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SE'ruortrt '�� <br /> STATE OF CALIFORNIP WATER RESOURCES CONTRO OARD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> �m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGEOFINFORMATION �PEFIM�ANTLY CLOSEDSITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE <br /> ,/INFORMATION <br /> &�ADDRESS— (MUST BE COMPLETED) <br /> RDAYSME <br /> E ryIw• " "' lw"•••"' �/(/Y N�+V�/ CARE OF ADDRESS INFORMATION <br /> `/ NEAREST CROSS STR ✓N+ M¶ON 0 POMAGM, Cl �FMRk AGM <br /> ATE AGEKV <br /> lf/V� <br /> INDIVIDUAL ❑ COUNIY-AGBILY <br /> STATCA ZIP C ✓/1/"' SITE PH JNE��/'# WITH R� j1DE <br /> �^ S 6 <br /> SINESS: ❑ 2 DISTRIBJfOfl ❑ < ESSOfl RESERVATIONGGf EPA IDM AT TH 8 SITE y <br /> STATION ❑ 3FARM W5 OTHER TRUST LANDS ❑ <br /> ENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> PHONE N WITH AREA CODE DAY . NAME( ST,FIST) PHONE N WITH AREA CODE <br /> EILAST•FIRST) / � / i, . �`f}( o �9 -01? Ciivr (n l�AAAME(LAST,FI ST) <br /> PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE.WITH AREA CODE <br /> ------------- <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAMEto indicate El nn ' <br /> ARTNERSHIP U STATE-AGENCY <br /> MAILING or STREET ADDRESS W� ✓S ORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> INDIVIDUAL Cl COUNTY-AGENCY <br /> STATE ZIP CODE PHONE.,WITH AREA CODE <br /> CIN NAME <br /> 111. TANK OWNER INFORMATION <br /> NFORM/A//TIIO�N.&A�DDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> STATE-AGENCY <br /> MAILING or STREET ADOR7 ✓S to intlicete ❑ PARTNERSHIP D <br /> RPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ II. ❑ 111• <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY% JURISDICTION x AGENCY M FACILITY ID% If of TANKS Et SITE <br /> ��O <br /> CURRENT LOCAL AGENCY FACILITY ID% APPROVED Y NAME PHONE 0 WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE 7. y-7 <br /> LOCATION ODE CENSUS TtU�Q. BUPERYISOR-DISTPICT CODE BU8INESY ANFILED -- NO ❑ DATE J IS <br /> vG <br /> CHECK% (((J PERMrr AMOUNNTT SURC R•G(�ENnAMOUNT FEE CODE RECEIPT. B� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST R MORE TANK PERMIT FORM'B'APPLICATION(S), UNLESS THIS I$A CHANGE OF SITE INFORMATION ONLY. <br /> FOR A(3-2-88) <br /> 4 w' \( P <br />